Order Code RL30970
CRS Report for Congress
Received through the CRS Web
Health in Russia and
Other Soviet Successor States:
Context and Issues for Congress
May 21, 2001
Jim Nichol
Analyst in Foreign Affairs
Foreign Affairs, Defense, and Trade Division
Lois McHugh
Analyst in International Relations
Foreign Affairs, Defense, and Trade Division
Congressional Research Service ˜ The Library of Congress

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Health in Russia and Other Soviet Successor States:
Context and Issues for Congress
Summary
Health issues in the New Independent States (NIS) of the former Soviet Union
have received increased U.S. attention in recent years. As part of this concern, a
January 2000 U.S. National Intelligence Estimate (NIE) highlighted global threats
posed to U.S. citizens and interests by increasing tuberculosis, hepatitis, HIV/AIDS,
and other infectious diseases outside U.S. borders. While mostly focusing on disease
threats emanating from Africa and Asia, the NIE also highlighted the NIS as an
emerging concern. It warned that increased political, military, social, and economic
disorder in the NIS could be worsened by the spread of disease, thereby setting back
NIS democratic and free market reforms, and that such instability might further
complicate U.S. arms control cooperation and efforts to contain the proliferation of
weapons of mass destruction. In addition, the NIE cautioned that NIS militaries
could face increased ill-health, harming the national security of the states in which
they are deployed, their effectiveness in international peacekeeping could be
diminished, and the troops could become agents for the spread of diseases among
U.S. and other peacekeepers, troops involved in international exercises and training,
and among civilian populations.
Congressional concerns about health conditions in the NIS have been reflected
in legislative language and other actions, but the major foci of U.S. policy have
remained democratic and economic reforms and arms control. U.S. health aid has
hovered at about 5-7% of all U.S. foreign assistance to the NIS in recent years, not
greatly increasing or decreasing, and cumulative U.S. aid obligations for FY1992-
FY2000 for health programs in the NIS are about 5% of about $16.5 billion for all
programs. While this aid is overshadowed by other U.S. aid priorities, many
policymakers and analysts have increasingly argued that health aid buttresses other
assistance.
The Foreign Operations Appropriations for FY2001 (P.L. 106-429) provides not
less than $45 million for child survival, environmental health, and combating
infectious diseases, and for related activities in the NIS. It also includes funds for
healthcare and environmental health epidemiology in Ukraine and for expanding
primary healthcare in Ukraine, Georgia, and Russia. Nonetheless, since FY1999, the
dollar amounts of U.S. health assistance to the countries of the NIS have increased
only to Tajikistan and declined for most other countries.
This report provides an overview of health conditions in the NIS, U.S. aid efforts
in recent years, and issues which Congress might consider in providing health
assistance to the NIS.

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Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Overview of U.S. Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Health in the NIS:
Context and Current Developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Selected Health Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Childhood and Maternal Mortality Rates . . . . . . . . . . . . . . . . . . . . . . 7
The Increase in Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Drug Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Alcoholism and Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Water-Borne Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Non-Medical indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Refugees and Displaced Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Orphans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
U.S. and International Health Aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
International Assistance Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Issues for Congress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
How Significant are NIS Health Issues to U.S. Interests? . . . . . . . . . . . . . 17
How Much Health Assistance Should the United States Provide
to the NIS? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
List of Tables
Table 1. U.S. Health Aid to the NIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Table 2. Health Spending and Life Expectancy . . . . . . . . . . . . . . . . . . . . . . . . 22
Table 3. Tuberculosis, HIV/AIDS, STD Rates
and Drug Users in the NIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Table 4. Refugees and Internally Displaced Persons . . . . . . . . . . . . . . . . . . . . . 24
Table 5. Abortion Rates and Contraceptive Use . . . . . . . . . . . . . . . . . . . . . . . 25

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Health in Russia and
Other Soviet Successor States:
Context and Issues for Congress
Introduction
During the Soviet era, health information was closely guarded and government
health statistics highly suspect. The Soviet government proclaimed the high quality
of its socialized healthcare system. Soviet data showed numbers of hospital beds and
doctors per capita as among the highest in the world and life spans comparable to
those in other developed countries. As became more apparent after the Soviet
collapse, such data were often incomplete or falsified and covered up substantial and
growing health problems.
The New Independent States (NIS) of the former Soviet Union1 faced problems
sustaining the huge, expensive, and ineffective healthcare systems they inherited.
Health conditions seemed to deteriorate during the 1990s, as measured by life
expectancy at birth, infant and maternal mortality, drug addiction, rates of infectious
disease, and other measures. On some measures, these states now face health
challenges common to developing countries, and these challenges are increasingly
braking their economic and democratic reforms, according to many observers.
Data on health and healthcare in the NIS are poor, but some general conditions
and trends may be discerned. Besides healthcare quality and access, factors affecting
health touched on but not analyzed in detail in this report include poverty rates,
conflict, living and working conditions, and the environment.
Overview of U.S. Policy
Although health issues in the NIS have been a lower priority in U.S. assistance
and relations than arms control and economic and democratic reforms, they have been
a matter of U.S. concern since the early 1990s and have received increased attention
in recent years. U.S. health assistance to the NIS began even before the collapse of
the Soviet Union with a public-private medical aid program to distribute
pharmaceuticals and medical supplies to the Soviet republics. Later, the Bush and
Clinton administrations led international efforts to address NIS needs, including
health needs. The 1992 Freedom Support Act (P.L.102-511), the major authorization
1The NIS generally include the Western NIS (Belarus, Moldova, Russia, and Ukraine), the
South Caucasian NIS (Armenia, Azerbaijan, and Georgia), and the Central Asian NIS
(Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan).

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CRS-2
for NIS aid, included the provision of medicine and medical supplies and equipment
and other aid to create quality healthcare and family planning services as priorities of
U.S. assistance.2 In the early 1990s, however, U.S. and Western donors lacked a
clear picture of health conditions in the NIS (largely because of the mostly sanguine
picture painted by Soviet health officials), and donors tended to assume that a short-
term aid infusion would put NIS health systems “back on their feet” in no time. As
health conditions became clearer, it was apparent that the NIS faced massive health
problems.
The Clinton Administration’s increased attention to global disease threats to U.S.
citizens and interests included a January 2000 U.S. National Intelligence Estimate
(NIE) on the implications for U.S. national security of rising infectious disease
outside U.S. borders. According to the NIE, the infectious disease burden will add
to political, military, social, and economic disorder in the NIS and could set back
democratic and free market reforms. Such instability might further complicate U.S.
arms control cooperation and efforts to contain the proliferation of weapons of mass
destruction. The NIE cautioned that NIS militaries already face increased ill health,
harming the national security of the states and the effectiveness of the armies in
international peacekeeping, and making the troops agents for the further spread of
diseases among U.S. and other peacekeepers, among U.S. and other troops involved
in international exercises and training, and among civilian populations.3
The January 2000 NIE and other Clinton Administration efforts to highlight
global disease as threatening U.S. interests were controversial. The Republican
Party’s 2000 campaign platform was critical of the NIE, stating that it had added
“disease . . . to an undiminished set of existing American responsibilities” in the world,
and asserted instead that “a Republican president will identify and pursue vital
American national interests.” However, the platform also supported U.S. assistance
for urgent humanitarian needs and for combating HIV/AIDS internationally.4 Richard
Armitage, now Deputy Secretary of State, stated during the presidential campaign
that “it is the height of insincerity to suggest that AIDS is at the top of our national
security list.”5 However, he argued in later confirmation hearings that the new foreign
affairs request would increase funding for HIV/AIDS, other infectious diseases, and
child survival, showing that the Administration was not “walking away” from these
2Silk Road Act language in P.L.106-113, signed into law in November 1999, also authorized
enhanced policy and aid to support humanitarian needs in the South Caucasus and Central
Asia, including the provision of medicines and medical equipment.
3U.S. National Intelligence Council, The Global Infectious Disease Threat and Its
Implications for the United States, NIE 99-17D, January 2000. Russian troops serve in
seven U.N. and Organization for Security and Cooperation in Europe missions, are
“peacekeepers” in Georgia, are stationed in Armenia, Georgia, Moldova, and Tajikistan, and
serve as advisors in India, Cuba, Peru, and Syria. See Johnson’s List, March 13, 2001.
4Republican National Convention. The Republican Party Platform 2000, July 31, 2000;
Council on Foreign Relations, Interview with Benjamin Gilman, August 3, 2000.
5Washington Post, February 14, 2001, p. A23.

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CRS-3
issues.6 Secretary Powell testified in March 2001 that increased foreign affairs
expenditures for child survival and diseases were a high priority of the Bush
Administration, noting that HIV/AIDS is “spreading into the [new] countries of the
[former] Soviet Union,” and terming HIV/AIDS a national security concern.7
U.S. policymaking on health issues in the NIS in the new Administration broadly
involves the State Department’s Office of the Coordinator for Assistance to the NIS,
the Special Advisor for the NIS, and USAID, the Department of Health and Human
Services (DHHS), and other agencies. The Coordinator for Assistance plays a major
role in integrating policy and implementation goals. USAID, the lead agency in
implementing healthcare aid programs in the NIS, has seconded the argument of the
January 2000 NIE that healthcare support helps ensure the success of other U.S. aid
for democratization, economic reforms, and the security of the NIS.
Some policymaking and coordinating efforts dealing with health aid are being
revamped by the new Administration. The new Administration eliminated an office
dealing with international health from the structure of the National Security Council,
a move criticized by a Clinton Administration official who argued that U.S. national
security is enhanced by assistance to prevent a nuclear-armed Russia and other
countries from “imploding” from an HIV/AIDS epidemic.8 The Bush Administration
also discontinued the U.S.-Russian Joint Commission on Economic and Technological
Cooperation and the U.S.-Ukraine Joint Commission, both of which had addressed
health and other cooperation. The Bush Administration has stated that while these
commissions will not be retained, health and other bilateral concerns will be discussed
“in other fora and other organizations” on a regular basis. Among these, the
Administration reportedly plans to address the international HIV/AIDS threat by
creating a high-level interagency task force and by adding a State Department role to
activities of the Office of National AIDS Policy.9
Congress has become increasingly concerned about the rising global threat of
infectious diseases, including HIV/AIDS, TB, and malaria, and has authorized and
appropriated funds to reflect that concern.10 Though primary attention in Congress
is focused currently on the threat these diseases pose in Africa, and much of the
increased funding is directed to African programs, there is some increased attention
to health problems in the NIS and other regions. Members of the House Banking
Committee (H.Rept.106-548), in reporting the Global AIDS and Tuberculosis Relief
Act of 2000 (P.L. 106-264), cited the January 2000 NIE to the effect that increases
in HIV/AIDS are threatening Africa, Asia, and the NIS. On the appropriations side,
6 Senate Foreign Relations Committee, Nomination for Deputy Secretary of State, March 15,
2001.
7Senate Foreign Relations Committee, March 8, 2001; Senate Budget Committee, March 14,
2001.
8Tom Malinowski, Senior Director for Speechwriting in the National Security Council.
Washington Post, February 9, 2001, p. A29.
9Washington Post, April 9, 2001, p. A2.
10For information on health aid legislation in the 106th Congress, see CRS Report RL30793,
Health in Developing Countries: The U.S. Response.

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Foreign Operations Appropriations for FY2001 (P.L. 106-429) allocated $963 million
for the Child Survival and Disease Programs Fund, including funds to combat
HIV/AIDS, polio, and other infectious diseases. A small amount ($6 million) for the
first time was made available to the NIS from this Fund. P.L.106-429 provided not
less than $45 million for NIS child survival, environmental health, and to combat
infectious diseases, and for related activities. This included not less than $1 million for
healthcare and environmental health epidemiology in Ukraine, including the study of
birth defects, and not less than $1.5 million to meet the health and other needs of NIS
victims of trafficking in persons. Infectious diseases of Congressional concern in the
NIS included HIV/AIDS and tuberculosis. While limiting aid to Russia if it continues
to cooperate with Iran on nuclear and missile technology matters, P.L.106-429
excluded aid for combating infectious diseases and for partnerships between U.S. and
Russian hospitals from this limitation.
Congress has generally appeared to support health assistance that amounts to
about 5 to 7 percent of overall aid to the NIS (see Table 1 at the end of the report).
This aid has been dwarfed by that provided for democratization and economic reforms
and arms control. U.S. aid obligations for FY1992-FY2000 for health programs in
the NIS are about 5% of about $16.5 billion for all programs for the NIS. Among
recent action, in February 2001, Representative Curt Weldon led a bipartisan
congressional delegation to visit legislators and medical officials in Russia, Ukraine,
and Moldova, which included discussions of healthcare needs and U.S. assistance.11
Health in the NIS:
Context and Current Developments
As part of the legacy of the former Soviet Union, the NIS inherited a large
centralized healthcare apparatus that provided good care for some medical conditions
but relied on outdated practices to treat many illnesses. The health of Soviet citizens
lagged behind that of U.S. and other Western populations in terms of access to many
new medical procedures and medicines and even in terms of prosaic measures such
as the number of hospitals and clinics with plumbing and heat. The healthcare system
emphasized a large number of specialized medical facilities with large staffs and
prolonged hospitalizations, rather than primary and preventive care, including regular
check-ups. The healthcare system was isolated from changing world standards of
treatment of diseases like TB, it followed secretive practices that prevented the
operation of a competent disease surveillance system, and it suffered from a lack of
medical supplies and equipment outside of the major medical centers. The creation
of the NIS exacerbated problems by creating international borders between healthcare
suppliers and customers and requiring re-negotiation of business relations that are still
not satisfactory.
Despite this shared legacy, the NIS emerged from the Soviet collapse with
varying health situations. Some of the NIS had better healthcare facilities than others,
and some had healthier populations at the beginning of the 1990s. A few had
11Congressional Record, February 28, 2001, p. H485-H493.

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suppliers of medical equipment or pharmaceuticals. Many observers have viewed
Central Asia’s population as having suffered the most from inadequate healthcare
during the Soviet period. The Western NIS had older populations than the Central
Asian states at the time of the Soviet collapse, reflecting differences in fertility and
mortality, providing age-related health challenges. Environmental catastrophe
affected health in several regions, including the Chernobyl area (radiation fallout in
Ukraine and Belarus), Chelyabinsk area (radiation contamination in Russia and
Kazakhstan), and the Aral Sea area (desertification in Kazakhstan and Uzbekistan).12
The NIS also differed in their rates of economic decline during the 1990s, and in such
related issues as healthcare funding, the diets of the people, and living conditions,
which affected infant survival and life expectancies. Conflicts in the NIS also
damaged health, leading to casualties, injuries, orphans, and displaced persons who
suffered physically and psychologically.
Health challenges in all the NIS loom larger because of the very low percentages
of gross domestic product (GDP) they devote to healthcare. Table 2 shows GDP per
capita in the NIS and the percent going to health. Health spending levels are low in
the NIS in comparison to the more than 8% on average spent in European Union
(EU) countries. In most of the NIS, government budgets (as opposed to private or
out-of-pocket spending) provide the bulk of funding for healthcare, but private
spending accounts for over one-half of spending in Armenia and over 80% in Georgia,
indicating heavy private burdens in these states. Given the low spending for
healthcare, the population’s ability to obtain healthcare when needed ranged from 50-
70% in the Western NIS to only 40-50% in the Central Asian NIS, according to one
estimate.13
In the post-Soviet era, demographers have been able to scrutinize previously
suppressed health data and conduct analyses that suggest that some aspects of the
health crisis in Russia and other NIS can be traced back to the 1960s. A major
indicator of overall health, life expectancy, peaked in the 1960s and began a
downward trend in Russia and other republics of the former Soviet Union by the late
1960s, perhaps caused by an increase in alcoholism, violence, tobacco use, and poor
diet. Another peak occurred in the mid-1980s (mostly attributed to government
restrictions on alcohol consumption), followed by a decline that deepened after the
Soviet breakup, though life expectancy in most NIS began to rise again after the mid-
1990s. Nonetheless, life expectancy remains lower than in most European states.
Life expectancy for males in the NIS in 2001 is 60.7 years (See table 2). This
compares unfavorably to 75.1 years for Western European males, and 74.4 years for
U.S. males.14
12Christopher Murray and Jose Bobadilla, in Premature Death in the New Independent
States, Washington, D.C., National Research Council, 1997, pp. 184-219. Other notable
overviews include Murray Feshbach and Alfred Friendly, Jr., Ecocide in the USSR, New
York, Basic Books, 1992; and Laurie Garrett, Betrayal of Trust, New York, Hyperion, 2000.
13U.S. Department of Defense. Defense Intelligence Agency. Armed Forces Medical
Intelligence Center (AFMIC), as reported in the January 2000 NIE.
14Russia’s demographic problems, however, are attributable not only to declining health, but
also to population dynamics, including the ripple effects of World War II and evolving family
(continued...)

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Some policymakers and analysts have warned that adverse health trends in
Russia – “unprecedented for an urban, literate society in the 21th century” – are
limiting its economic potential and “reducing its influence on the international stage,”
and may even raise the specter of political disintegration and the subsequent
establishment of authoritarian rule hostile to Western interests.15 Causes of bad health
in Russia include cardiovascular disease, untreated chronic illnesses (high blood
pressure, diabetes, high cholesterol), alcoholism (contributing to homicide, vehicular
accidents, and suicide), drug abuse, and infectious disease. The threat of large
increases in HIV/AIDS, hepatitis, and TB could further depress life expectancy.
Russia has not implemented systematic healthcare reforms. Hospitals and clinics
remain largely government-owned, though there are private physicians and a private
health insurance industry. Compulsory payroll contributions for healthcare began in
1993, but basic public health issues involving sanitation, pharmaceuticals,
vaccinations, ambulances, and the distribution of medical staff countrywide remain
unresolved. While Russian policy and U.S. aid programs have emphasized the
theoretical economic benefits of decentralization of healthcare to the regions, some
health experts have argued that decentralization has harmed healthcare, at least in the
short term, in part because many public health issues are not fully addressable at the
regional level.16 Perhaps reversing what some observers have termed a policy of
governmental “malign neglect” of health issues, Russian President Vladimir Putin in
his April 2001 state-of-the-nation address criticized the lack of fundamental reforms
of the Soviet-era healthcare system, the lack of federal and local budgetary support
for healthcare, inadequate functioning of the insurance system, and the widespread
demand by state hospitals and doctors for illicit under-the-table payments.
The collapse of healthcare in Central Asia has been reflected in decreasing life
spans, continuing high abortion rates, high infant and maternal mortality rates, and
increases in cardiovascular/circulatory, parasitic, infectious, and respiratory diseases.
While the spread of TB and hepatitis in Central Asia is most worrisome, the U.N.
Secretary General has pointed to rising HIV/AIDS rates in Kazakhstan and elsewhere
in Central Asia as a global concern.17 Poor sanitation and increasing drug abuse,
tobacco and alcohol use, malnutrition, diet deficiencies, and tainted blood supplies
14(...continued)
planning attitudes. See U.S. Department of Commerce. Bureau of the Census. Ward
Kingkade, Population Trends: Russia, International Brief IB/96-2, February 1997; George
Demko, Grigory Ioffe, and Zhanna Zayonchkovskaya, eds., Population Under Duress,
Boulder, CO: Westview Press, 1999, pp. 9, 24-27, 48, 55-56.
15Nicholas Eberstadt, Kennan Institute, February 5, 2001; Demko, p. 63; Murray Feshbach,
Washington Quarterly, Winter 2001, p. 16-18.
16 Diane Duffy in Vicki L. Hesli and Margaret H. Mills, eds., Medical Issues and Health
Care Reform in Russia, Lewiston, N.Y., Edwin Mellon Press, 1999, pp. 47-48, 52-53; United
Nations. World Health Organization. Highlights on Health in the Russian Federation,
November 1999, p. 23.
17United Nations General Assembly, Review of the Problem of Human Immunodeficiency
Virus/Acquired Immunodeficiency Syndrome in All its Aspects, Report of the Secretary-
General, A/55/779, February 16, 2001, pp. 5, 13-14.

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contribute to declining health. Kyrgyzstan has made the most progress in healthcare
reforms (though its fragile economy places them at risk), and Tajikistan the least. The
health consequences of poor quality healthcare seriously constrain economic
development in the region, according to USAID.18
Selected Health Indicators
By looking at how a country measures up in certain categories of health over
time, it is possible to get a picture of the health situation in that country.
Unfortunately, another legacy of the Soviet healthcare system is the lack of reliable
health statistics and an unreliable system for collecting them. The Soviet Union did
not follow U.N. World Health Organization (WHO) methods for birth and death
statistics and the NIS are only slowly moving to implement them. Both factors make
it difficult to compare health indicators across the NIS and with other countries. In
order to make comparisons, this report uses statistics from the United Nations.
Although these also rely on government provided information, the various U.N.
agencies adjust them with their own estimates. Nonetheless, the statistics used in this
paper should be used only as a general view of the situation in and among the NIS and
should not be assumed to be directly comparable to U.S. or European health statistics.
Most observers agree that the early 1990s saw major declines in health in
virtually all NIS in terms of such measures as infant mortality, alcoholism, and
cardiovascular disease. From 1995 onward, as NIS economies began to stabilize,
there were improvements (or slowing declines) in these health conditions. Concerning
other problems, such as infectious diseases, tobacco use, and drug addiction, the
situation has become worse. By most measures, health in the NIS in 2001 continues
to lag behind that in most developed countries.
Childhood and Maternal Mortality Rates. Table 2 shows mortality rates
for children under five years of age. According to USAID, increasing mortality rates
in the NIS among children under five years old are telling signs of the deterioration
of healthcare and the plight of many families suffering from poverty and
malnutrition.19 USAID estimates that mortality rates for children under five years of
age increased in all the NIS over the period 1990-1997, the worst record in all its
geographic bureaus.20 Health surveys conducted by Kazakh medical institutes
suggest that infant mortality is much higher in the late 1990s than implied in
government data, raising the implication that in poorer Central Asian states, infant
18USAID, Infectious Disease Assessment, pp. 1-2; USAID, Health Program Review: Central
Asia: September-November 1999, p. 2; Kevin Rushing, USAID Central Asian Republics
Desk Officer, Paper, Panel on Public Health and Environmental Issues, Harvard Colloquium
on International Affairs, March 11, 2000.
19 Infant mortality is generally used to determine the overall health of a country. However,
because most of the NIS still use the Soviet system of measuring infant mortality, which
undercounts deaths by as much as 50 percent, this report uses under 5 years of age mortality
statistics.
20USAID Economic Strategy in Central Asia, November 10, 1999, p. 9; USAID’s Assistance
Strategy for Central Asia 2001-2005, July 2000, p. 56; Broadening the Benefits of Reform,
p. 11, from U.S. Census Bureau data.

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CRS-8
mortality rates may also have increased. In Tajikistan, malnutrition has contributed
to an “alarming” degree of stunted, underweight, and wasting children, according to
a Save the Children NGO report.21 Maternal mortality rates are much higher in the
NIS than in many other European countries (see Table 5). Causes include poor
nutrition, lack of maternal care, and extremely high rates of abortion, compared to the
United States and most of Europe. High rates of abortion and maternal mortality are
being reduced in several NIS by education and access to other contraceptive methods
(Table 5).
Childhood vaccination rates in the NIS declined dangerously in the late 1980s
and early 1990s, contributing to a diphtheria epidemic in the early 1990s. By the mid-
1990s, this epidemic accounted for 90% of worldwide cases. Ukraine, Russia, and
Tajikistan were hardest hit. USAID collaborated with WHO in delivering vaccines
and the United States later advocated international donor assistance for childhood
immunizations. By the latter 1990s, diphtheria cases had declined greatly, as had
some other childhood diseases thanks to these efforts.
The Increase in Infectious Diseases. The sharp deterioration of the health
infrastructure due to economic conditions has contributed to a dramatic increase in
infectious disease cases. Increasing levels of infectious diseases such as TB,
HIV/AIDS, and malaria have raised great concerns from the international community.
The U.N. Program on HIV/AIDS (UNAIDS) and the WHO “Stop TB” program
provide statistics for all the NIS which are considered reliable. Comparable statistics
for other infectious diseases are not available. Table 3 shows the number of new
cases of TB and the numbers living with HIV/AIDS.
Tuberculosis. TB, including drug-resistant TB, appears to be increasing in
most of the NIS because of poor living conditions and inadequate treatment. Drug-
resistant TB can be extremely costly to treat, further burdening already strained
healthcare finances in the NIS. WHO ranks Russia among the top ten countries
worldwide in terms of new cases of TB, and at the bottom among twenty-three
countries with high TB rates in use of an effective TB treatment termed the Directly
Observed Treatment Short-course (DOTS). WHO and the Russian Health Ministry
have begun to implement a five-year plan for DOTS coverage in Russia that would
reach about one-half of the population. Rates of drug-resistant TB have increased
dramatically, especially in 1998 when then-President Boris Yeltsin announced an
amnesty that released tens of thousands of prisoners with TB into the general
population. The Russian Health Ministry also has announced that Chechnya and
surrounding areas with high numbers of displaced persons have become a major locus
of drug-resistant TB.
TB rates in all the NIS except Armenia are higher than in the rest of Europe. The
highest numbers of new cases besides Russia are in Kazakhstan, Ukraine, and
Uzbekistan. TB and hepatitis now account for 5% of deaths in Kazakhstan and
Kyrgyzstan, although USAID’s support for DOTS in Kazakhstan may have
21USAID, Rushing; U.S. Save the Children, Not By Bread Alone: Household Livelihood
Security in Rural and Urban Tajikistan, June 2000, p. 34.

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contributed to a significant decline in TB from 1998 to 1999, for the first time since
rates climbed in 1990.
HIV/AIDS. U.N. Secretary General Kofi Annan in February 2001 highlighted
the NIS as a major risk zone for the increase in HIV/AIDS, warning that the NIS
present “an extremely steep increase in the number of new infections,” which is one
“of the most dramatic trends in the worldwide AIDS epidemic.” Although the actual
numbers are small, compared to Africa and parts of Asia and Latin America, the NIS
has the fastest rate of growth of HIV/AIDS infection in the world. The Secretary
General argued that a window of opportunity “still exists for effective targeted
interventions, particularly among injecting drug users” if the NIS governments show
commitment.22
During the 1990s, the NIS witnessed growth in injecting drug use, prostitution,
and population mobility that spread HIV/AIDS, but many of the governments are
slow to recognize the growing HIV/AIDS threat. HIV/AIDS infection rates in
Ukraine are the highest among the NIS and the highest in Europe, according to the
UNAIDS. The number of confirmed cases in Russia has tripled in the last year.
Official statistics in Russia record 80,000 cases of HIV/AIDS, but UNAIDS
estimates some 130,000 Russians were infected in 1999, and that two times that
number, 300,000, were probably infected in 2000. Russian AIDS official Vadim
Pokrovsky has asserted that “in fact, half a million Russians are infected,” with cases
fueled by an HIV “epidemic” among injecting drug users (IDUs). The incidence of
HIV/AIDS in Russia as a percent of its population, he suggests, could match U.S.
levels this year, and up to 700,000 Russians could die from AIDS within 10-12 years
if remedial efforts are not taken.23
Central Asia’s inadequate health care system and growing injecting drug use
leave it vulnerable to an explosive increase in HIV/AIDS cases, according to some
assessments. UNAIDS official Henning Mikkelsen has suggested that Central Asia
“may well be on the verge of a major public health and socioeconomic development
disaster, in terms of large scale epidemics of HIV/AIDS,” because of rising drug use.
Sexually Transmitted Disease (STD) rates in Kyrgyzstan, Kazakhstan, Belarus, and
Moldova are high, another indication that HIV/AIDS infections will also rise if
unchecked.
Drug Addiction. All of the NIS face increased injecting drug use (see Table
3), with the greatest estimated increases in Russia, Ukraine, Turkmenistan, and
Uzbekistan. In all of the NIS, demand reduction efforts are inadequate, according to
the U.S. State Department's International Narcotics Control Strategy Report,
because of inadequate budgets, inadequate treatment services in rural areas, and a lack
of focus on drug use prevention by officials.
22United Nations General Assembly, Review of the Problem of Human Immunodeficiency
Virus/Acquired Immunodeficiency Syndrome in All its Aspects, Report of the Secretary-
General, A/55/779, February 16, 2001, pp. 5, 13-14.
23Andrei Shukshin, Reuters, March 13, 2001; Agence France-Presse, January 9, 2001; FBIS,
February 3, 2001.

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Drug treatment is poor or lacking in most of the NIS, and where available,
mainly entails involuntary confinement after arrest. Treatment consists of
detoxification with little or no follow-up rehabilitation efforts. The 1998 Russian
narcotics law provides for the involuntary commitment of drug users who come to the
attention of the authorities, which many observers criticize as preventing most addicts
from seeking treatment. International HIV/AIDS expert Kasia Malinowska-
Sempruch suggests that there may be 200,000 drug addicts in Kazakhstan and
120,000 in Tajikistan. In Central Asia, she states, drug treatment is “so scarce as to
be virtually nonexistent,” and drug users avoid seeking treatment out of fear of arrest
by authorities. Laws are mostly aimed at interdiction and punishment of drug
traffickers and users. In major cities in Tajikistan and Kyrgyzstan, heroin is cheaper
to buy than vodka, according to the nongovernmental Open Society Institute,
threatening to lead to much higher future drug addiction rates in these NIS.24 An
Uzbek law “on narcotic substances and psychotropic agents” took effect in 2000 that
authorizes compulsory blood testing for suspected drug use and involuntary
commitment that, like the Russian law, inhibit addicts from seeking treatment.
Turkmenistan claims that it has the most progressive drug treatment program in the
NIS, consisting of six drug treatment centers where addicts can seek voluntary and
confidential treatment, but these centers cannot serve the entire population. Religious
and non-governmental organizations have opened several drug rehabilitation centers
throughout Ukraine.
High-level attention to the drug problem in Russia was demonstrated on March
13, 2001, when Premier Mikhail Kasyanov convened a government commission to
study increasing drug abuse and HIV/AIDS cases among youth. Revealing the
inaccuracy of official drug abuse figures, Kasyanov stated that the official number of
drug addicts, 450,000 as of January 2001, was a fraction of the real number. He
warned that Russia had changed from a drug transit country to a consumption
country, and that organized crime was increasingly involved in the drug market.
Recognizing that a comprehensive counternarcotics strategy must be adopted that
embraces demand reduction and rehabilitation as well as law enforcement, Russian
officials have met with the U.S. Office of National Drug Control and Prevention to
discuss how to set up an analogous agency.
Alcoholism and Smoking. Alcohol consumption in Russia and many other
NIS remains much higher than in most of the world. Russian observers have stressed
that alcoholism is linked to other causes of increased mortality in Russia, including
traffic accidents and injuries (homicides and suicides). Alcohol consumption in Russia
declined briefly in the mid-1980s as a result of a sobriety campaign, but rose
thereafter.25 In 1993, there was a large increase in male alcohol poisoning in Russia,
24Matthew Curtis, Eurasianet, February 21, 2001 and March 2, 2001; Open Society Institute,
International Harm Reduction Project, Uncovering the Dangers of Drug Use in Kazakhstan,
Kyrgyzstan and Tajikistan; Peak Options Consulting, for the Open Society Institute,
Summary of Fact Finding Mission to Kyrgyzstan, March 1, 2001.
25Vladimir Treml, in Herlemann, pp. 151-162. According to Russian analysts Vladimir
Shkolnikov and Alexander Nemtsov, “in the period from 1988-1992, the biggest share of the
increase in Russian mortality was attributable to alcohol consumption.” Premature Death
(continued...)

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CRS-11
along with increases in male homicide and suicide and in circulatory and respiratory
diseases. According to many observers, deaths from alcoholism in Russia have
increased recently.26
According to the WHO, smoking in most of the NIS continued to increase
during the 1990s. In Russia, the majority of adult males smoke, while in the EU
countries, rates of smoking are declining. Smoking has been linked to high
percentages of male deaths among those aged 35-69 in Russia, Kazakhstan, Ukraine,
Armenia, and Belarus, substantially higher than in the United States.27
Water-Borne Disease. Deteriorating water and sewer systems (often water
and sewer pipes are co-located), in conjunction with other causes such as injecting
drug use, are linked to large increases in the incidence of hepatitis, cholera, and
typhoid fever throughout the NIS. Russian media reported that hundreds of people
in towns near Moscow contracted hepatitis type-A in January 2001 from
contaminated drinking water. Russian health authorities also warned in early 2001 of
the spread of cholera as well as intestinal diseases in Chechnya, because sewer
systems are nonfunctional in Grozny. Poor sanitation and hygiene lead to yearly
outbreaks of hepatitis-A at the beginning of school in Turkmenistan and Uzbekistan.
Hundreds of typhoid fever cases in southern Tajikistan were reported by the Tajik
media during the winter of 2000-2001, attributed to poor drinking water. Increasing
cases of malaria and encephalitis in Tajikistan associated with mosquito-infested
drainage systems are also of growing concern.28
Non-Medical indicators
Increasing numbers of people in the NIS belong to subgroups that face special
health needs, including orphans, refugees, and the internally displaced.
Refugees and Displaced Persons. NIS health conditions have been
impacted by the large number of persons forced from their homes by warfare and
discrimination since the breakup of the Soviet Union. The U.N. High Commissioner
for Refugees has estimated that during the 1990's as many as nine million people left
their homes in the NIS. These included refugees who fled their country’s warfare,
those displaced within their own country by war or returned from exile to find their
25(...continued)
in the New Independent States, pp. 232-233.
26Premature Death in the New Independent States, pp. 240-241, 256; Feshbach, Washington
Quarterly, p. 19.
27United Nations. World Health Organization. Highlights on Health in the Russian
Federation, November 1999, p. 19; Premature Death in the New Independent States, pp.
274, 275-286, 287-313.
28For healthcare problems in Chechnya and Ingushetia, see Bill Frelick, Refugee Reports,
Special Issue 2001, p. 2; Humanitarian Situation of Refugees and Internally Displaced
Persons from Chechnya, Committee on Migration, PACE, Doc.8944, January 23, 2001; U.N.
World Health Organization, North Caucasus Briefing/Update Activity Report, February 4,
2001.

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CRS-12
homes and communities destroyed, and those forced to leave their homes, denied
citizenship or declared aliens in their homeland under new residence or citizenship
laws. Lack of routine health care and immunization, poor food and sanitation,
exposure to disease, and violence against vulnerable groups all result in declines in
health among those living in crowded refugee camps or makeshift housing.
Major humanitarian emergencies caused by conflict have occurred in Armenia,
Azerbaijan, Georgia, Russia, and Tajikistan. During the 1990s, conflict resulted in
the exile or displacement of some 300,000 Armenians, over 500,000 Azerbaijanis,
325,000 Georgians, and 450,000 Chechens and other Russian residents, according to
the U.N. High Commissioner for Refugees29. Major populations that relocated
because of changes in ethnic status in the new republics included ethnic Russians
returning to Russia (3 million between 1992 and 1996), and Tatars returning to
Ukraine (250,000 between 1988-1999). While aid agencies responded to the health
needs of the refugees and some of the displaced, for the most part, their health
remains precarious since the political causes of their displacement have not been
resolved, and they have limited access to health services and to a better life. Table 4
shows the current estimates of refugees and displaced in the NIS.
Orphans. According to UNICEF, the numbers of children aged 0-3 years
placed in orphanages greatly increased in all the Western NIS and in Kazakhstan over
the period 1991-1998, from an average of 165 children per 100,000 population in
1991 to an average of 304 children in 1998 for these NIS. The number of such
children in 1998 in other NIS was substantially lower, about 39 per 100,000. While
numbers of institutionalized children have been growing, declining public funding has
led to increasingly poorer care. The orphanages in the NIS, unlike in most of
Europe, often include children with birth defects, mental disabilities, and chronic
health conditions. USAID and international NGOs have increasingly provided
assistance, including urgent and other healthcare. The numbers of homeless and street
children in Russia and other NIS reportedly also have expanded, and these children
are helped only on an ad hoc basis by existing healthcare programs and most
international aid.30
U.S. and International Health Aid
Soon after the Soviet collapse, USAID focused on healthcare reforms in the NIS
as one of its objectives. It developed the Hospital Partnership Program, to be carried
out by a newly created American International Health Alliance (AIHA), as its major
public-private vehicle for aid efforts focusing on educational activities and
professional exchanges by U.S. medical volunteers. A related Health Reform Project
by USAID launched in 1993 focused on the reorganization of healthcare institutions
29United Nations. High Commissioner for Refugees. The State of the World’s Refugees
2000, p.185-209.
30United Nations. United Nations Children’s Fund. Young People in Changing Societies,
2000, p. 153. On conditions in Russia and recommendations to international aid donors, see
Human Rights Watch, Cruelty and Neglect in Russian Orphanages, December 1998.

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and financing in the NIS, to “increase economic efficiencies, quality of care, access,
and provider choices in the NIS through market-oriented reforms.” These changes
have faced obstacles in Russia and other NIS, including Soviet-era healthcare
establishments and officials that balk at change and skyrocketing poverty rates, which
have placed fee-for-service healthcare out of reach for many people.31 However, the
changes are seen by USAID as essential to the ability of the healthcare systems to
modernize and function on their own without ongoing international donor assistance.
The Clinton Administration asked Congress in 1997 to begin supporting a new
“Partnership for Freedom” initiative as part of boosted NIS assistance that would
emphasize grass-roots economic and social reforms, including health. Additional aid
was sought for hospital and health facility partnerships, Defense Department-supplied
hospital equipment and supplies, programs to combat infectious diseases, and efforts
to bolster clean water supplies, childhood survival, and maternal health.32 Rationales
for the initiative included that it countered negative social impacts of the economic
transition in the NIS and that it “shows that Americans indeed care.”33 The request
for a large boost in NIS aid was not supported by Congress, but many of the
programmatic emphases, including health aid, were endorsed.34
Building on the “Partnership for Freedom” initiative, USAID in 1998-1999
increasingly emphasized social needs in the NIS. USAID came to argue that
economic reforms in the NIS had not always contributed to the growth of middle
classes, but also helped create “a new class of chronically poor,” who lost the meager
state benefits they received under communism. While democratization and economic
reforms remained U.S. objectives, USAID stressed that without adequate healthcare
and other social services, populations in the NIS would lose faith in the reform
process, and economic productivity, restructuring, and reforms would be harmed.
USAID stated that it would increasingly take social issues into account in designing
and implementing programs, so that “the broadest possible spectrum of [NIS]
citizens...have the opportunity to enjoy the benefits of reform.”35
31Edward Burger, Jr., in Russia’s Torn Safety Nets, ed. by Mark Field and Judyth Twigg,
New York, St. Martin’s Press, 2000, pp. 291-292; About AIHA, see [http://www.aiha.com].
Burger criticizes the Health Reform Project as “clearly out of phase with the political and
economic realities of the time in Russia.”
32Spurring these emphases, conferrees on Foreign Operations Appropriations for FY1997
(H.Rept.104-863) had criticized the Administration for not including health and environmental
health as NIS aid priorities, and had urged that the treatment of childhood illnesses in Ukraine
related to Chernobyl supercede other aid objectives. See CRS Report RL30148, U.S.
Assistance to the Soviet Union and Its Successor States, p. 29.
33U.S. House of Representatives. International Relations Committee. Statement of Richard
Morningstar, March 26, 1998.
34CRS Report RL30418, U.S. Assistance to the Soviet Union and Its Successor States
1991-1999, pp. 29-32.
35USAID, Budget Justification FY2001, Annex III, Europe and Eurasia, p. 9. See also
USAID, Broadening the Benefits of Reform in Central and Eastern Europe and the New
Independent States: A Social transition Strategy for USAID, Bureau for Europe and Eurasia,
(continued...)

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CRS-14
In keeping with the new emphasis, USAID’s assistance activities were divided
into three broad strategic areas, economic, democratic, and social transition. The
objectives of social transition assistance include improving NIS health and other social
benefits and services. USAID healthcare goals include helping the NIS to draw up
healthcare and insurance legislation and policy focusing on community-based primary
health care; to improve the cost-effectiveness of healthcare budgets; to improve the
quality of healthcare; to educate citizens about their personal healthcare rights and
obligations; and to reduce environmental and occupational health risks.
USAID provides the bulk
Cumulative Obligations FY1992-FY2000 for
of U.S. health aid to the NIS,
Health and Related Programs
though some has also been
(Freedom Support Act and Other Funds)
provided by the Defense,
(million dollars)
Health and Human Services,
USAID Healthcare Improvement
346.87
and Energy Departments (see
Presidential Medical Initiative
5.0
text box on this page). Table 1
Operation Provide Hope transport costs
195.0*
shows the amount of health aid
Defense Department Excess Defense
to the NIS provided by
Articles: Hospitals and Related
225.8
Peace Corps Health Education
26.0**
USAID in FY1999-FY2001.
DHHS Biotechnology Engagement Prog.
11.38
U.S. assistance obligated
Subtotal U.S. Government Health Aid
810.05
FY1992-FY2000 for health
Coordinator’s Office privately-donated
was less than 5% of total aid
cargoes
1,500*
obligations to the NIS of $16.5
Total
2,310.05
billion, indicating the relatively
low priority of such aid,
Sources: State Department, Freedom Support Act FY2000
though recent years have
Annual Report; Background Paper on State Department-
indicated a fairly steady U.S.
Directed Humanitarian Assistance to the NIS, January 11,
2001; Conversation with Coordinator’s Office, April 17,
aid commitment amounting to
2001; The Peace Corps, Congressional Budget Presen-
about 5-7% of NIS aid. In
tation, FY2002.
recent years, Russia, Ukraine,
*Health-related; Estimate by the Coordinator’s Office
Kazakhstan, Uzbekistan, and
**Estimated: a program breakdown by health activities in
Armenia have received the
the NIS is not available, but the Peace Corps reports that
about 20% of global projects involve health.
largest amounts of health aid,
partly reflecting broad U.S.
policy interests in these states.
Within each NIS, the percentages of U.S. aid devoted to health as opposed to other
programs have been highest in the Central Asian states in recent years (usually more
than 10%), reflecting heightened U.S. concerns about urgent health needs and poor
healthcare situations in these states or low levels of aid overall.
U.S. government health aid to the NIS has been supplemented by large-scale
private donations of medical goods and expertise worth about $1.5 billion during
FY1992-FY2000, including those provided through the NIS Health Partnerships
program, implemented by AIHA (private donations that do not use U.S. subsidized
transport are not included in this total). The AIHA leverages USAID funding to
foster cooperation between U.S. hospitals and healthcare providers and NIS medical
35(...continued)
February 2000, pp. 8-9, 23-24.

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facilities and experts. Twenty-eight primary healthcare initiatives have been launched
by AIHA in Armenia, Azerbaijan, Moldova, Russia and Ukraine, and an emergency
medical services partnership in Uzbekistan. Operation Provide Hope, an interagency
program launched in 1992, provides U.S. funded transport services for private
donations of medical goods. The combination of U.S. public and private health-
related assistance amounts to about 12% of total aid obligated in FY1992-FY2000.
USAID programs include small-scale demonstration projects in various regions
of the NIS that it is hoped NIS governments will replicate nationwide. USAID has
maintained that its performance measures show that its health programs are having
some impact in the NIS. While heralding these impacts, USAID nonetheless cautions
that more assistance is needed, since “systemic trends in the region remain disturbing”
because of rising rates of HIV/AIDS, tuberculosis, and multi-drug resistance
tuberculosis, and inadequate improvements in healthcare systems. Progress has been
made in lowering the high rates of abortion in the NIS, for instance, but abortion rates
are still among “the highest in the world.”36
To promote access to quality health care in Russia, the Quality Assurance
Project funded by USAID helped to improve the outcomes of primary care treatment.
In partnership with the American College of Physicians, information was provided to
Russian physicians on the treatment of hypertension, cardiovascular disease, diabetes,
and TB. In addition, an Evidence Center in Primary Care Medicine was created at the
Moscow Medical Academy, and training sessions were held for physicians from
Russia and other NIS on substance abuse prevention. In FY2000, the USAID’s
Women and Infants' Health Project in Russia carried out training on post-abortion
care and STD counseling; training on breast-feeding and newborn care; and surveys
on mother and child health indicators.37
Among other recent U.S. agency health-related programs, the Energy
Department allocated $3 million per year beginning in FY1999 for studies on radiation
health in the NIS. The DHHS’s Biotechnology Engagement Program and the U.S.
Department of Agriculture’s Collaborative Biotechnical Research Program are
supporting the redirection of former Soviet biological warfare scientists to peaceful
research, with a focus on healthcare (such as the control of tuberculosis, hepatitis,
HIV/AIDS and other infectious diseases). In addition, some activities of the Moscow
and Kiev Science Centers, funded by the State Department, deal with biomedical
research by NIS scientists. With major U.S. backing, a Civilian Research and
Development Foundation NGO was set up in 1995, including a Biomedical and
Behavioral Sciences Program that carries out collaborative medical research, funded
by the U.S. State, Defense, and Commerce Departments NIH, and others.
Peace Corps health-related programs in the NIS have included preventive health
education programs in Armenia, Kazakhstan, and Moldova, community health
development programs in Turkmenistan and Uzbekistan, and environmental education
36Broadening the Benefits of Reform, pp. 8, 38; FSA Annual Report FY2000.
37See also Centers for Disease Control and Prevention, Office of Global Health, and the
Agency for Toxic Substances and Disease Registry, Working with Partners to Improve
Global Health: A Strategy for CDC and ATSDR, September 2000.

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in Kazakhstan, Russia, and Ukraine. The Defense Department has donated military
hospitals under the Excess Defense Articles program and has provided follow-on
equipment packages and training worth $225.8 million to all the NIS during FY1992-
FY2000 except Tajikistan and Turkmenistan.38
International Assistance Efforts. International organizations with health
programs in the NIS include the World Health Organization(WHO), the U.N. Fund
for Population Activities, UNICEF, U.N. Development Program and the World Bank.
With the increased effort to curb the spread of HIV/AIDS, and the establishment of
UNAIDS, a consortium of seven U.N. agencies, health programs have become a
growing part of the activities of the U.N. International Drug Control Program and
UNESCO (U.N. Educational, Scientific, and Cultural Organization) as well. The
European Union’s TACIS program also addresses health issues.
WHO’s European office in 2000-2001 provided small amounts of aid to
Armenia, Azerbaijan, Kyrgyzstan, Moldova and Tajikistan ($463,000), Russia
($200,000), and other NIS ($130,000). The programs focus on communicable
diseases, non-communicable diseases and health promotion, health policy, health care
reform, women’s and children’s health, and environment and health. Each country
has a WHO special representative. WHO also has technical assistance programs in
the NIS countries funded both by the WHO regular budget and by voluntary
donations from members. In the 2000-2001 biennium, the proposed funding was $3.4
million from regular budget funds and $5.3 million from voluntary contributions.39
The NIS are also included in European regional programs and some WHO global
initiative projects funded directly by WHO’s regional office for Europe.
Coordinated U.N. interagency HIV/AIDS programs in all the NIS have been
operating since the early to mid-1990s. Most of these countries also have active
private voluntary organization partners and programs run by bilateral aid agencies
such as USAID. The projects address the populations currently most likely to spread
HIV/AIDS (injecting drug users, prostitutes, and men who have sex with men),
education for young people and schoolchildren, vulnerable groups (prisoners, street
children, refugees, ethnic minorities), care for people living with HIV/AIDS and for
their human rights, condom distribution, blood safety programs, prevention and
treatment of STDs, disease surveillance, and public service information on
HIV/AIDS. Program totals for 1997 for the entire region, including governmental
and nongovernmental sources, were over $18 million and covered several years
according to a UNAIDS survey in 199940 About two-thirds of the funds went to
Russia. Additional millions were available for region wide programs. A December
2000 donors’ meeting on HIV/AIDS in Russia included a promised loan of $150
million for TB and HIV/AIDS from the World Bank covering several years. Some
38Peace Corps, Congressional Budget Presentation, FY2002; Background Paper on State
Department-Directed Humanitarian Assistance to the NIS, January 11, 2001.
39See [http://www.who.int/wha-1998/EB_WHA/english/new/ANG_navigat.htm] .
40Snapshot of external support for national responses to the epidemic of HIV/AIDS in Central
and Eastern Europe (including Central Asia) as reported by co-sponsors, bilateral agencies
and NGOs. UNAIDS. October 1999.

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CRS-17
Russian health officials are concerned that loan will be more expensive because it will
require the use of Western pharmaceuticals and procedures instead of cheaper
domestic products. Critics of the current Russian health system argue that Russian
medical leaders are refusing to adopt better western methods of addressing diseases
such as TB and HIV/AIDS.41
UNICEF has health and nutrition programs in all the NIS. Program totals in
1999 ranged from a high of $882,000 in Russia to a low of $152,000 in Belarus,
according to UNICEF. The U.N. Population Fund also has programs in all the NIS.
The average annual UNFDA funding level since 1998 ranges from $100 million in
Belarus to $785 million in Kazakhstan.
The TACIS program is the major technical assistance program of the European
Union for the NIS. Its most recent report, covering 1999, indicates that 427.6 million
Euros (about $380.6 million in current dollars) committed to the NIS for
developmental or technical assistance programs. Support for health sector reform is
mentioned as one TACIS emphasis, but the report listed only two health projects,
private financing of health services in Russia and Uzbekistan. 42
Issues for Congress
How Significant are NIS Health Issues to U.S. Interests?
Though the debate over whether infectious disease is an important national
security concern is not over, the Administration, Congress and most Americans agree
that the uncontrolled spread of infectious disease and especially HIV/AIDS is a
danger to Americans, both in the United States and abroad. Current U.S. aid to the
NIS emphasizes arms control and security, suggesting that these are far more
important to U.S. national security. While the rapid growth in HIV/AIDS cases, large
numbers of drug resistant TB cases, and outbreaks of infectious diseases are
worrisome, the rates of infection are not as great in the NIS as in some areas of Africa
and Asia and arguably do not pose as severe a near-term threat to U.S. interests.
Should the United States reprogram some recently focused U.S. policy initiatives and
assistance to troubled regions in Africa and Asia and shift aid to the NIS? Or is it
likely that health problems will be resolved by the NIS themselves as their economies
improve?
The U.S. military views the rise of infectious and other diseases in the NIS and
the poor quality of healthcare as factors endangering U.S. troops during military
training, exchanges, exercises and operations involving the NIS. The diphtheria
epidemic in Russia in the early 1990s, for instance, was traced to Soviet troops returning from
Afghanistan and infected troops rotated out of Tajikistan. On the other hand, the U.S.
military is always concerned about protecting personnel from disease. NIS military
41The Washington Post, May 8, 2001.
42Commission of the European Communities. Report from the Commission. The TACIS
Programme Annual Report 1999. Brussels, December 20, 2000. COM (2000) 835 final.

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CRS-18
personnel are no more dangerous than the personnel of other countries with large
health problems.
Another serious concern is that the health crisis undermines U.S. economic and
political transition policies in the NIS. Adverse health trends in Russia may be a drag
on economic reforms that are conducive to U.S. investments, foster civil unrest,
encourage a countervailing political authoritarianism, and perhaps lead to a more
internationally belligerent, nuclear-armed Russia.43 Even small increases in health aid
may pay big dividends in lowering disease rates and ameliorating social discontent in
the NIS. Some call for much larger commitments to meet pressing health needs in the
NIS, perhaps by shifting aid from democratization and economic reform programs.
On the other hand, as Table 2 indicates, governments of the NIS are spending a very
small percentage of their budgets on health. Without government commitments to
health, U.S. assistance is likely to do little to improve the NIS health status.

U.S. security interests may be served by bolstering the health of the NIS
militaries and the general populations. Declining health in the NIS militaries can harm
their abilities to combat terrorism and drug trafficking and otherwise to defend the
territorial integrity of the NIS. If the NIS militaries are less capable of carrying out
these missions, then U.S. border and security aid (recently boosted by the
Administration and Congress), may be less effective than anticipated, according to this
argument. Also, terrorist groups may be able to gain more adherents where failing
healthcare systems create disaffected populations. U.S. health aid has been
considered by several NIS militaries as a major benefit of military-to-military
cooperation, according to U.S. defense officials.
However, money alone will not resolve health problems in the NIS. Health
problems are often caused by sanitation system failures and environmental degradation
– such as radiation hazards in Kazakhstan’s Semipalatinsk nuclear testing site or the
evaporation of the Aral Sea – that will require large-scale remediation support.
Health problems caused by alcohol abuse, drug abuse, and malnutrition have societal
roots which must be addressed.
How Much Health Assistance Should the United States
Provide to the NIS?
Congress and the Clinton Administration clashed for several years over the level
of aid to provide for the countries of the NIS. Current U.S. health aid to the NIS
comprises between 5 and 7 percent of total aid to the region. Due to cuts in the
overall aid program since FY1999, however, the actual amount of health aid has
increased only to Tajikistan. One way to address the need for more assistance would
be to increase the percent of foreign aid devoted to health in the NIS or to establish
Congressional guidelines for the amount of aid to be provided for health assistance.
FY2001 was the first year Congress included the NIS in the Child Survival and
Disease account, where most health money is provided. Until this year, health
programs in the NIS were entirely funded through the Freedom Support Act, where
health programs competed with many other programs. Either of these changes would
43Nicholas Eberstadt, Kennan Institute, February 5, 2001.

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CRS-19
require a change in U.S. policy which currently focuses on democratization and
economic reforms and arms control. Also, there may be a need to consider longer-
term health aid commitments, particularly if U.S. assistance focuses more on
healthcare institution-building and reform efforts that aim to bolster the ability of the
NIS to meet their own needs.
A second possible change in health aid to the NIS would be to alter the
distribution of aid among the countries of the NIS. Table 1 shows the distribution of
USAID’s bilateral health funds to the NIS in recent years. The largest aid amounts
have gone to Armenia, Kazakhstan, Russia, Ukraine and Uzbekistan. Much less
health assistance has been provided to Azerbaijan, Belarus, Moldova, Tajikistan, and
Turkmenistan. These latter countries have the highest rates of under five mortality and
are among the lowest in ranking of health system performance in the NIS, according
to the World Health Organization.
Before changing the distribution or amount of health aid provided, policymakers
must consider whether U.S. health assistance should be targeted to the most needy
NIS, to the closest or most strategic U.S. friends, or to the most democratic and
market-oriented NIS. Such determinations are complicated by the added desirability
of targeting U.S. aid to NIS where the governments are receptive, honest, and
efficient at carrying out healthcare reforms, but these conditions are not currently met
in any of the NIS.44 In Russia and other NIS, many critics charge, the governments
are inefficient, highly corrupt, and not focused on health budgets, policies, and
stewardship.45 In such conditions, U.S. and international medical assistance to the
NIS risks being undermined or redirected for political purposes. In some cases, NIS
governments have blocked medical as well as other humanitarian aid to civilians for
political and military purposes (such as in Chechnya), using it as a weapon to bring
populations and separatist movements into line. To help circumvent problems with
governments, some suggest that U.S. health aid should focus more on high-quality
indigenous health-related non-governmental organizations in the NIS, to ensure that
aid is used properly and to strengthen long-term self-help capabilities, while others
caution that in most of the NIS, such local NGOs are still hard to find. Some in
Congress have raised concerns that U.S. funding for health-related research by former
biological warfare scientists, aimed at keeping them employed in peaceful endeavors
and retraining them, may be misused by NIS governments to maintain the warfare
skills of the scientists.46
44Gro Harlem Brundtland, Director-General of WHO, has argued that governments should not
only provide adequate budgetary support and policies facilitating public and private
healthcare, but also proper “stewardship” to maximize healthcare performance dollar for
dollar. U.N. WHO, The World Health Report 2000, pp. viii-ix, 119-141, 200-203.
45Nicholas Eberstadt, Kennan Institute, February 5, 2001, argues that the Russian leadership
has failed, compared to other societies facing economic turmoil, to provide adequate
healthcare, partly because of an undemanding Russian public. Ukrainian demographer
Valentyna Steshenko has been critical that “neither the public in Ukraine nor their leadership”
focus on “the preservation and improvement of public health as one of the nation’s most
important priorities.” FBIS, January 24, 2001.
46U.S. General Accounting Office, Biological Weapons: Effort to Reduce Former Soviet
(continued...)

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CRS-20
In most but not all cases, U.S. health assistance has been exempt from
restrictions on aid to particular countries. USAID family planning programs in the
NIS must comply with policy promoting maternal health and the provision of modern
contraception methods that counteract the inordinately high rates of abortion
throughout the region. Likewise, with HIV/AIDS spreading throughout the NIS
primarily through injecting drug users, U.S. programs to curb the spread of the
disease must comply with restrictions on U.S. drug assistance programs. (For details
on NIS aid issues, see CRS Issue Brief IB95077, The Former Soviet Union and U.S.
Foreign Assistance, updated regularly.)
Many in Congress suggest that other industrialized countries should bear a
greater share of NIS health assistance. These countries may not have the same U.S.
legislative restrictions, allowing them to address these problems in a different manner.
Although information on bilateral assistance to the NIS is sketchy, TACIS, the major
aid program of the European Community, devoted very little of its budget to health
programs. On the other hand, U.S. advocacy of greater Western involvement has in
the past acted to spur European donors.
46(...continued)
Threat Offers Benefits, Poses New Risks, NSIAD-00-138, April 28, 2000; House Committee
on Armed Services, National Defense Authorization Act for FY2001, H.Rept. 106-616, May
12, 2000, pp. 421, 422-423.

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CRS-21
Table 1. U.S. Health Aid to the NIS
Country
USAID
USAID
USAID
USAID
FY1998
FY1999
FY2000
FY2001
Health
Health
Health
Planning
Funding
Funding
Funding
for Health
($ millions)
($ millions)
($ millions)
($ millions)
Armenia
1.98
4.6
4.6
4.6
Azerbaijan
0.0
2.5
2.87
1.5
Belarus
0.4
0.6
0.35
0.0
Georgia
3.55
5.3
4.04
3.705
Kazakhstan
4.28
7.05
5.1
5.71
Kyrgyzstan
2.28
2.43
3.0
2.3
Moldova
0.6
1.0
0.03
0.45
Russia
6.79
11.77
11.2
11.32
Tajikistan
0.45
0.8
1.0
1.5
Turkmenistan
0.65
2.15
1.3
0.9
Ukraine
9.55
8.8
4.26
5.095
Uzbekistan
2.48
7.26
4.6
5.0
Regional
2.34
4.75
3.06
5.133
Total
35.35
59.01
45.06
45.09
As Percent of
4.59%
6.97%
5.39%
5.58%
NIS Funding
Sources: USAID, Budgets for Health Care Programs in Eurasia

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CRS-22
Table 2. Health Spending and Life Expectancy
Country
GDP
Health
Life
Life
Under-5
Per
Spending
Expectancy
Expectancy
Mortality
Capita
as % of
1999 Male
1999 Female
Rate/1,000
1999
GDP
1998
Armenia
$485.5
7.9%
72.3
77.1
18.4
Azerbaijan
$498.5
2.9%
67.8
75.3
33.2
Belarus
$777.0
5.9%
62.4
74.6
14.3
Georgia
$517.0
4.4%
69.4
76.7
17.5
Kazakhstan
$1,058.0
3.9%
58.8
69.9
28.9
Kyrgyzstan
$263.8
4.0%
61.6
69.0
40.7
Moldova
$271.0
8.3%
64.8
71.9
22.2
Russia
$1,249.0
5.4%
62.7
74.0
20.3
Tajikistan
$176.0
7.6%
65.1
70.1
--
Turkmenistan
$381.7
4.3%
61.0
65.3
60.0
Ukraine
$619.5
5.6%
64.4
74.4
17.3
Uzbekistan
$304.2
4.2%
65.8
71.2
38.0
Sources: Estimated GDP data are from the European Bank for Reconstruction and Development,
Transition Report 2000. Health spending (based on 1997 data) and life expectancy data are from
the U.N. World Health Organization, World Health Report 2000. Data for under-five mortality are
f r o m U N I C E F M O N E E o n - l i n e r e p o r t
[http//www.eurochild.gla.ac.uk/documents/monee/welcom.htm] .

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CRS-23
Table 3. Tuberculosis, HIV/AIDS, STD Rates
and Drug Users in the NIS
Country
New TB
Living with
Number
Estimated
Cases
HIV/AIDS, End of
Diagnosed for
Number of
Reported
1999
the First Time
Drug
in 1998
with Syphilis or
Abusers
Adults
Children
Gonorrhea, Rate
(0-14)
per 100,000 in
1998
Armenia
1,381
<500
<100
39.8
10,000
Azerbaijan
4,672
<500
<100
21.1
13,500
Belarus
6,150
14,000
<100
261.5
5,000
Georgia
4,876
<500
<100
79.75
20-25,000
Kazakhstan
20,623
3,500
<100
238.8
37,408
Kyrgyzstan
5,706
<100
<100
353.5
--
Moldova
2,625
4,500
<100
260.0
5,000
Russia
121,434
130,000
1,800
336.5
2 million+
Tajikistan
2,448
<100
<100
32.3
--
Turkmenistan
3,839
<100
<100
80.1
250-
300,000
Ukraine
31,318
230,000
7,500
194.7
100,000+
Uzbekistan
14,558
<100
<100
75.0
200,000
Sources: U.N. World Health Organization. Global Tuberculosis Control: WHO Report 2000.
Geneva, 2000; for HIV/AIDS, see UNAIDS, Report on the Global Epidemic, June 2000; for STDs,
see U.N. Children’s Fund. Young People in Changing Societies. The MONEE Project.
CEE/CIS/Baltics Regional Monitoring Report No. 7, 2000.

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CRS-24
Table 4. Refugees and Internally Displaced Persons
(as of December 31, 1999)
Country
Refugees
Displaced/Forced
Migrants
Armenia
296,200
--
Azerbaijan
221,600
569,600
Belarus
260
16,400
Georgia
5,200
281,000
Kazakhstan
14,800
25,200
Kyrgyzstan
10,800
6,800
Moldova
10
--
Russia
80,100
1,408,200
Tajikistan
4,500
8,400
Turkmenistan
18,500
--
Ukraine
2,700
260,000
Uzbekistan
1,000
--
Source: U.N. High Commissioner for Refugees. State of the World’s Refugees 2000. Information
as of Dec. 31, 1999.

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CRS-25
Table 5. Abortion Rates and Contraceptive Use
Maternal
Abortion Rates
Contraceptive Use:
Mortality/
(abortions per 100
All Methods**
100,000*
live births)*
Country
1998
1989
1998
Year
Percent
Armenia
25.5
34.7
46.5
1990
21.6%
Azerbaijan
41.1
21.5
20.1
1990
17.2%
Belarus
28.1
163.5
152.2
1995
50.4%
Georgia
34.2
75.6
44.9
1990
17.1%
Kazakhstan
54.9
77.5
67.1
1999
66.1%
Kyrgyzstan
35.5
66.3
27.0
1997
59.5%
Moldova
36.3
97.3
80.4
1997
73.7%
Russia
44.0
204.9
182.8
1994
66.8%
Tajikistan
58.2
20.1
19.1
1990
20.8%
Turkmenistan
16.3
31.3
25.7
1990
19.8%
Ukraine
27.2
153.2
125.3
1990
23.4%
Uzbekistan
9.6
27.8
13.5
1996
55.6%
Sources:
* UNICEF MONEE Regional Monitoring Report No. 7.
** U.S. Bureau of the Census. International Data Base.

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